Gastroenterology Flashcards
(171 cards)
1
Q
What is pellagra?
A
Deficiency of vitamin B3, niacin
2
Q
What are the clinical features of pellagra?
A
Dermatitis, diarrhoea, dementia/delusions, leading to death
3
Q
Name the only routinely recommend supplement in patients with alcoholism
A
Thiamine supplements
4
Q
What are the cardic pathologies associated with carcinoid syndrome?
A
Tricuspid insufficiency and pulmonary stenosis
5
Q
What is the best measure of acute likler failure?
A
INR (prothrombin time)
6
Q
What part of the colon is most likely to be affected in ischaemic colitis?
A
Splenic flexure
7
Q
What type of cancer is associated with achalasia?
A
Squamous cell carcinoma of the oesophagus
8
Q
What type of cancer is associated with Barrett’s oesophagus?
A
Oesophageal adenocarcinoma
9
Q
What vaccination is given to patients with coeliac disease?
A
Pneumococcal vaccine due to hyposplenism
10
Q
You review a 34-year-old man who has had ulcerative colitis for the past 20 years. He describes a one week history of passing three bloody stools per day. Despite this he is eating well and denies abdominal pain.
Abdominal examination is unremarkable. What is this episode most likely to represent?
A
Mild exacerbation of ulcerative colitis
11
Q
- A 62-year-old presents with upper abdominal pain. She has recently been discharged from hospital where she underwent an ERCP to investigate cholestatic liver function tests. The pain is severe. On examination she is apyrexial and has a pulse of 96 / min.
- What is the most likely diagnosis?
A
Acute pancreatitis
12
Q
A 76-year-old woman presents with abdominal pain, distension and vomiting. She recently had an episode of acute cholecystitis and is awaiting a cholecystectomy. She feels her symptoms have returned over the past few days. On examination her abdomen is distended.
What is the most likely diagnosis?
A
Gallstone ileus
13
Q
What is the most likely diagnosis?
A
Ulcerative colitis
14
Q
Describe the clinical features of Plummer-Vinson syndrome
A
Dysphagia, glossitis and iron-deficiency anaemia
15
Q
What scoring system is used after endoscopy and provides a percentage risk of rebleeding and mortality?
A
Rockall score
16
Q
Watery travellers diarrhoea with stomach cramps and nausea.
What is the most likely cause?
A
Enterotoxigenic E. coli
17
Q
Name 3 gluten-free starchy foods
A
Rice, potatoes and corn (maize)
18
Q
What is the first line test for diagnosis of small bowel overgrowth syndrome?
A
Hydrogen breath testing
19
Q
Name 1 important side-effect of clindamycin
A
Diarrhoea (C. difficile)
20
Q
Name 1 finding on biopsy consistent with a diagnosis of gastric adenocarcinoma
A
Signet ring cells
21
Q
If symptoms of constipation don’t respond to a bulk-forming laxative such as isphagula husk. what should be tried next?
A
Osmotic laxative e.g. macrogol
22
Q
What is the first line antibiotic for use in patients with C. difficile infection?
A
Oral vancomycin
23
Q
How can you treat severe acute hypophosphataemia in adults?
A
Intravenous infusion of phosphate polyfusor
24
Q
What pattern of liver disease is associated with paracetamol overdose?
A
Hepatocellular picture of liver disease
25
A 56-year-old woman who is known to have gallstones presents with severe epigastric pain and vomiting. On examination she is apyrexial and tender in the epigastrium.
What is the most likely diagnosis?
Acute pancreatitis
26
What malignancy is associated with primary sclerosing cholangitis?
Cholangiocarcinoma
27
What genetic dynrome is associated with Zollinger-Ellison syndrome?
MEN type 1
28
What is the management of a liver abscess?
Combination of antibiotics & drainage
29
Hepatitis B serology: what does HBsAg indicate?
* Acute disease - present for 1-6 months
* If present for over 6 months indicates chronic disease
30
Hepatitis B serology: what does anti-HBs indicate?
* Implies immunity (either exposure or immunisation)
* It is negative in chronic disease
31
Hepatitis B serology: what does IgM antiHBc indicate?
* Implies previous (or current) infection
* Appears during acute/recent hepatitis B infection and is present for about 6 months
32
Hepatitis B serology: what does IgG antiHBc indicate?
* Implies previous (or current) infection
* Persists after acute infection
33
Hepatitis B serology: what does HbeAg indicate?
Results from breakdown of core antigen from infected liver cells as is, therefore, a marker of HBV replication and infectivity
34
What is Maddrey's discriminant function?
* Formula which decides whether to start glucocorticoid therapy in alcoholic hepatitis
Calculated by a formula based on the prothrombin time and serum bilirubin
35
What are the side effects of oral aminosalyclates?
* Diarrhoea
* Nausea
* Vomiting
* Exacerbation of colitis
* Acute pancreatitis (significantly more common as a side-effect with mesalazine than sulfasalazine)
36
Metabolic ketoacidosis with normal or low glucose. What should you consider?
Alcoholic ketoacidosis
37
What is Courvoisier's law?
States that in the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones and is most likely to be due to malignancy, particularly pancreatic malignancy
38
What drug is used first-line to maintain remission in patients with Crohn's
Azathioprine or mercaptopurine
39
What is the diagnostic investigation of choice for pancreatic cancer?
High-resolution CT pancreas
40
What is the management of a mild-moderate flare of ulcerative colitis extending past the left-sided colon?
Oral aminosalicylates should be added to rectal aminosalicylates, as enemas only reach so far
41
What blood result can indicate an upper GI bleed versus lower GI bleed?
High urea levels
42
What is the most likely diagnosis?
Oesophageal cancer
## Footnote
Apple core sign
43
What anti-emetic should be avoided in bowel obstruction?
Metoclopramide
44
What is the is the investigation of choice for suspected carcinoid tumours?
Urinary 5-HIAA
45
How long must a patient eat gluten for before testing for coeliac disease?
At least 6 weeks
46
By what mechanism does loperamide act through to slow down bowel movements?
Reduction in gastric motility through stimulation of opioid receptors
47
Low BP secondary to blood loss + deranged LFTs.
What is the most likely diagnosis?
Ischaemic hepatitis
48
How do you monitor treatment in haemochromatosis?
Ferritin and transferrin saturation
49
List some of the complications of GORD
* Oesophageal carcinoma
* Barrett's oesophagus
* Anaemia
* Benign strictures
50
How do you screen for haemachromatosis?
* General population: transferrin saturation
* Family members: HFE genetic testing
51
What is the management of a perianal abscess in Crohn's?
Incision and drainage
52
If a mild-moderate flare of distal ulcerative colitis doesn't respond to topical (rectal) aminosalicylates then what should be added?
Oral aminosalicylates
53
A 54-year-old female presents with a 3 month history of dysphagia affecting both food and liquids from the start, along with symptoms of heartburn.
What is the most likely underlying diagnosis?
Achalasia
54
How should a severe flare of UC be treated in hospital?
IV corticosteroids
55
What is the inheritence pattern of haemochromatosis?
Autosomal recessive
56
What is a Sister Mary Joseph nodule?
Sign of metastasis to periumbilical lymph nodes, classically from gastric cancer primary
57
What can cause increased ferritin without iron overload?
* Inflammation (due to ferritin being an acute phase reactant)
* Alcohol excess
* Liver disease
* Chronic kidney disease
* Malignancy
58
A 44-year-old obese female is noted to have gallstones during an abdominal ultrasound, which was requested due to repeated urinary tract infections. Apart from the repeated UTIs she is otherwise well.
What is the most appropriate management of the gallstones?
Observation
59
What is the most likely diagnosis?
Crohn's disease
## Footnote
There is a long segment of narrowed terminal ileum in a 'string like' configuration in keeping with a long stricture segment. Termed 'Kantor's string sign'.
60
What does the image demonstrate?
Diverticulosis
## Footnote
Shows multiple outpouchings of the colonic wall, which are characteristic of diverticulosis
61
What anti-emetic is contraindicated in Parkinsonism?
Metoclopramide
62
T2DM with abnormal LFTs.
What diagnosis shold you consider?
Non-alcoholic fatty liver disease
63
Patients with ascites secondary to liver cirrhosis should be given what drug?
Aldosterone antagonist e.g. spironolactone
64
In an acute upper GI bleed, what scoring system can identify low risk patients who may be discharged?
Blatchford score
65
A 55-year-old man presents to the Emergency Department with a short history of 24 hours of dark urine, pale stools and right upper quadrant pain. He mentions he is a part-time teacher and smokes 10 cigarettes a day. He has no relevant past medical history and is not on any medications.
On examination, his sclera appear yellow and his BMI is 29 kg/m².
Which of the following investigations will be the most valuable?
Abdominal ultrasound
66
A 40-year-old man presents with symptoms of dysphagia that have been present for many months. His investigations demonstrate lack of relaxation of the lower oesophageal sphincter during swallowing.
What is the most likely diagnosis?
Achalasia
67
A 4-year-old presents with sudden onset of dysphagia. He undergoes an upper GI endoscopy and a large bolus of food is identified in the mid oesophagus. He has no significant history, other than a tracheo-oesophageal fistula repair soon after birth.
What is the most likely diagnosis?
Benign oesophageal stricture
68
What is the most likely diagnosis?
Ulcerative colitis
## Footnote
This image demonstrates the complete loss of haustral markings in the distal part of the bowel ('lead pipe colon'), consistent with ulcerative colitis
69
What venous blood gas results are associated with prolonged vomiting?
Hypochloraemic metabolic alkalosis
70
How do you calculate alcoholic units?
Alcohol units = volume (ml) * ABV / 1,000
71
What investigations are first line in suspected IBS?
Full blood count, ESR, CRP, antibody testing for coeliac disease - endomysial antibodies or tissue transglutaminase
## Footnote
Should be normal - to rule out other diagnoses
72
What are the features of the Truelove and Witts' severity index?
Assesses the severity of UC in adults
Ulcerative colitis is classified as 'severe' when the patient has blood in their stool, or is passing more than 6 stools per day plus at least one of the following features:
* Temperature greater than 37.8°C
* Heart rate greater than 90 beats per minute
* Anaemia (Hb less than 105g/ L)
* Erythrocyte sedimentation rate greater than 30 mm/hour
73
Which surgical treatment is used for achalasia?
Heller cardiomyotomy
74
Long history of watery green diarrhoea post cholecystectomy. What is the treatment
Bile-acid malabsorption → cholestyramine
75
Arecurrent episode of C. difficile within 12 weeks of symptom resolution should be treated with what?
Oral fidaxomicin
76
What drugs should be stopped in C. difficile infections?
Anti-peristaltic drugs such as opioids can predispose to toxic megacolon
77
What malignancy are patients with pernicious anaemia at increased risk of?
Gastric carcinoma
78
What antibodies are associated with type 1 autoimmune hepatitis?
Antinuclear antibodies, anti-smooth muscle antibodies and raised IgG levels
79
What antibodies are associated with type 2 autoimmune hepatitis?
Anti-liver/kidney microsomal type 1 antibodies (LKM1) (affects children only)
80
What are the characteristic electrolyte disturbances seen in patients with refeeding syndrome?
Hypophosphataemia, hypokalaemia and hypomagnesaemia
81
What lifestyle advice would you give to a patient wth ascites?
Reducing dietary sodium
82
How is an upper GI bleed anatomically identified?
The definition of an upper GI Bleed is a haemorrhage with an origin proximal to the ligament of Treitz
83
Anti-HBs positive, anti-HCV positive, all others negative.
What does this suggest?
Previous HBV vaccination, cleared HCV infection
84
HBsAg negative, anti-HBs positive, IgG anti-HBc negative.
What do these results suggest?
Previous immunisation
85
If a patient with ulcerative colitis has had a severe relapse or >=2 exacerbations in the past year what should you prescribe?
Either oral azathioprine or oral mercaptopurine to maintain remission
86
What blood test is used to diagnose coeliac disease?
Total IgA and IgA tTG
87
What region of the GI tract is affected in UC?
Inflammation starting at the rectum and not spreading beyond the ileocaecal valve (proctitis)
88
A 23-year-old student who has recently returned from a trip to North Africa presents with anorexia, nausea, mild right upper quadrant pain and lethargy. Blood tests show a marked elevation of his alanine aminotransferase level.
What is the most likely diagnosis?
Viral hepatitis
89
What pattern of LFT derangement is seen in pancreatic cancer?
Cholestatic LFTs
90
What are the investigations of choice in primary sclerosing cholangitis?
ERCP/MRCP
91
A combination of liver and neurological disease points towards what diagnosis?
Wilson's disease
92
What is the AST/ALT ratio in alcoholic hepatitis?
2:1
93
What type anaemia is associated with pernicious anaemia?
Macrocytic anaemia
94
What is the first-line investigation for a suspected perforated peptic ulcer?
Erect CXR
95
What investigation is required in all patients admitted to hospital with suspected upper GI bleeed and within what timeframe?
Endoscopy within 24 hours of admission
96
What is Peutz-Jegher's syndrome?
Autosomal dominant inherited condition associated with the growth of multiple benign polyps
97
Describe the presentation of Peutz-Jegher's syndrome
* Presenting complaint often small bowel obstruction seconday to a GI hamartoma
* Associated with spots of dark blue to dark brown macules around the face, hands, feet, oral mucosa and anus
98
You see a 52 year old lady in the General Practice surgery. She is complaining of progressive dyspepsia, dysphagia and fatigue. She describes a long history of dark brown stools, but no fresh blood is present. She has not had any unexpected weight loss. She had surgery for a peptic ulcer 10 years ago.
Investigations discover she has H. pylori.
What is the next step?
2 week wait referral to endoscopy
99
Describe the histology associated with Crohn's disease
* Inflammation in all layers from mucosa to serosa
* Increased goblet cells
* Granulomas
* Skip lesions
100
Describe the histology associated with UC
* No inflammation beyond submucosa
* Neutrophils
* Crypt abscesses
* Depletion of goblet cells
* Continuous disease
101
Describe the findings on endoscopy associated with Crohn's disease
Deep ulcers, skip lesions - 'cobble-stone' appearance
102
Describe the findings on endoscopy associated with UC
Widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps ('pseudopolyps')
103
What is the management for complex perianal fistulae?
Draining seton
104
What is the most sensitive and specific lab finding for diagnosis of liver cirrhosis in those with chronic liver disease?
Thrombocytopenia (platelet count <150,000 mm^3)
105
True/false: portal hypertension is a cause of hepatomegaly
False
106
What vitamin deficiencies are likely to be seen in coeliac disease?
Iron, folate and vitamin B12
107
What findings on AXR are associated with gallstone ileus?
Small bowel obstruction and air in the biliary tree
108
Positive anti-HBc IgG, negative anti-HBc IgM and negative anti-HBc in the presence of HBsAg.
What do these results indicate?
Chronic HBV infection
109
A transjugular intrahepatic portosystemic shunt procedure connects which two vessels?
Connects the hepatic vein to the portal vein
## Footnote
Aims to treat portal hypertension by making route for blood to flow from the portal circulation to the systemic circulation, bypassing the liver
110
A 42-year-old haemophiliac who is known to be HIV positive presents with pain on swallowing for the past week. He has been generally unwell for the past 3 months with diarrhoea and weight loss.
What is the most likely diagnosis?
Oesophageal candidiasis
111
What drugs are associated with cholestasis?
* COCP
* Antibiotics: fluclox, co-amox
* Anabolic steroids, testosterones
* Chlorpromazine, prochlorperazine
* Sulphonylureas
112
What is the most likely diagnosis?
Oesophageal cancer
## Footnote
The barium swallow shows 5cm of irregular narrowing of the mid-thoracic oesophagus with proximal shouldering, consistent with oesophageal cancer
113
A 38-year-old woman presents with fever, malaise and jaundice. On examination she has moderate hepatomegaly. Laboratory analysis confirms a positive anti-smooth muscle antibody and anti-nuclear antibody. Antimitochondrial antibodies are negative.
What is the most likely diagnosis?
Autoimmune hepatitis
114
What is the treatment of choice for small bowel bacterial overgrowth syndrome?
Rifaximin
115
A 66-year-old man presents to his GP with progressive dysphagia. Initially this was only with solid food, but lately he is having trouble swallowing even soup. Which investigation is the gold standard?
Endoscopy
116
Deranged LFTs combined with secondary amenorrhoea in a young female strongly suggest what diagnosis?
Autoimmune hepatitis
117
. A 68-year-old man with type 2 diabetes is admitted to hospital unwell. On examination he has features of septic shock and right upper quadrant tenderness. He is not jaundiced. Imaging shows a normal calibre bile duct and no stones in the gallbladder.
What is the most likely diagnosis?
Acalculous cholecystitis
118
A 34-year-old lady is admitted with a 3 day history of colicky right upper quadrant pain which radiates to her back. The pain is now more constant. On examination she is not jaundiced, but has a temperature of 38.5oC. She has localised peritonism in the right upper quadrant.
What is the most likely diagnosis?
Acute cholecystitis
119
Do you need to check H. pylori status after treatment if symptoms have resolved?
No
120
What is the investigation of choice for suspected perianal fistulae in patients with Crohn's?
MRI
121
What investigation can be useful for diagnosing and monitoring the severity of liver cirrhosis?
Transient elastography
122
Dysplasia on biopsy in Barrett's oesophagus requires what intervention?
Endoscopic mucosal therapy
123
What is the preferred and most effective mode of treatment for achalasia in a young patient without multiple comorbidities?
Pneumatic dilatation
124
How do you differentiate between iron deficiency anaemia and anaemia of chronic disease?
TIBC is high in IDA, and low/normal in anaemia of chronic disease
125
Positive anti-HBc IgG, negative anti-HBc IgM and negative anti-HBc in the presence of HBsAg.
What do these results suggest?
Chronic HBV infection
126
What gene mutations are associated withene mutationshereditary non-polyposis colorectal carcinoma?
MSH2/MLH1
127
What should be prescribed to patients with ascites (and protein concentration <= 15 g/L) as prophylaxis against SBP?
Oral ciprofloxacin or norfloxacin
128
HBsAg positive, anti-HBs negative, IgM anti-HBc positive
What do these results suggest?
Acute infection
129
Patient in a coma with hepatic encephalopathy. What grade?
IV
130
What are the side effects of metoclopramide?
* Extrapyriamidal effects e.g. acute dystonia
* Diarrhoea
* Hyperprolactinaemia
* Tardive dyskinesia
* Parkisonism
131
What is the first line investigation for Budd-Chiari syndrome?
| What
Ultrasound with Doppler flow studies
132
What blood results are associated with coeliac disease?
Mild anaemia, a calcium, phosphate and vitamin D deficiency combined with an isolated rise in ALP (anaemia + osteomalacia)
133
What is the most appropriate medication to start in a patient with ascites secondary to liver cirrhosis?
Spironolactone
134
Urea > 12 indicates (upper/lower) GI bleed?
Upper
135
What malignancy are patients with coeliac disease at increased risk of?
Enteropathy-associated T cell lymphoma
136
What blood tests are used to monitor treatment in haemochromatosis?
Ferritin and transferrin saturation
137
What are the adverse effects of PPIs?
* Hyponatraemia, hypomagnasaemia
* Osteoporosis → increased risk of fractures
* Microscopic colitis
* Increased risk of C. difficile infections
138
What is the standard procedure to diagnosis primary sclerosing cholangitis?
MRCP
139
What are the early signs of haemochromatosis?
Fatigue, erectile dysfunction and arthralgia
140
What is the most likely diagnosis?
Ulcerative colitis
## Footnote
Lead pipe colon, ankylosis of the left sacroiliac joint and partial ankylosis on the right
141
Describe the clinical features of intestinal angina (chronic mesenteric ischaemia)
Triad of severe, colicky post-prandial abdominal pain, weight loss, and an abdominal bruit
142
What drugs must be stopped before a urea breath test?
No antibiotics in past 4 weeks, no antisecretory drugs (e.g. PPI) in past 2 weeks
143
What is the most common symptom of Crohn's disease in children?
Abdominal pain
144
What is the characteristic iron study profile in haemochromatosis?
Raised transferrin saturation and ferritin, with low TIBC
145
What features make up the triad of acute liver failure?
Encephalopathy, jaundice and coagulopathy
146
When should PPIs be stopped before an upper GI endoscopy?
At least 2 weeks before
147
HBsAg negative, anti-HBs positive, IgG anti-HBc positive
What do these results indicate?
Previous infection, not a carrier
148
What is the most common site affected in UC?
Rectum
149
What are the most useful antibodies when investigating vitamin B12 deficiency?
Intrinsic factor antibodies
## Footnote
Gastric parietal cell antibodies have low specificity
150
What drug should be administered alongisde isoniazid to reduce the risk of peripheral neuropathy?
Pridoxine (vitamin B6)
151
Name a diagnostic marker for HCC
AFP (raised)
152
Name 3 risk factors for small bowel overgrowth syndrome
* Neonates with congenital gastrointestinal abnormalities
* Scleroderma
* Diabetes mellitus
153
What drugs are used to eradicate H. pylori?
PPI + amoxicillin + clarithromycin, or
PPI + metronidazole + clarithromycin
Importance
154
What is hepatorenal syndrome?
A type of functional kidney impairment that occurs in patients with advanced liver disease
155
What are the key features of hepatorenal syndrome?
Ascites, low urine output, and a significant increase in serum creatinine
156
What is the first line treatment for hepatorenal syndrome?
Terlipressin
157
What is the first-line medication for primary biliary cholangitis?
Ursodeoxycholic acid
158
What is the diagnostic investigation of choice for pancreatic cancer?
High resolution pancreas CT
159
Describe the clinical presentation of pancreatic cancer
Painless jaundice, pale stools, dark urine, and cholestatic liver function test results
160
Describe the features of hepatomegaly associated with right heart failure
Firm, smooth, tender and pulsatile liver edge
161
If a mild-moderate flare of distal ulcerative colitis doesn't respond to topical (rectal) aminosalicylates, what should be added?
Oral aminosalicylates
162
What is the gold standard for diagnosis of coeliac disease?
Jejunal biopsy
163
Dysplasia on biopsy in Barrett's oesophagus requires what?
Endoscopic intervention
164
What blood results are associated with Wilson's disease?
ALT raised, urinary copper raised, serum caeruloplasmin reduced
165
What are the features of a carcinoid tumour?
Flushing, diarrhoea and bronchoconstriction
166
Describe the presentation of a duodenal ulcer
Pain several hours after eating
167
What artery can be affected by a ruptured duodenal ulcer?
Gastroduodenal artery
168
What drugs are used first-line to maintain remission in patients with Crohn's?
Azathioprine or mercaptopurine
169
MRCP shows a 'double duct' sign. What is the most likely diagnosis?
Pancreatic cancer
170
What factors are associated with a poor prognosis in liver cirrhosis?
* Presence of ascites
* Raised bilirubin
* Decreased albumin
* Increased prothrombin time
* Presence of encephalopathy
171
Mild-moderate flare of ulcerative colitis does not respond to topical or oral aminosalicylates.
What's next?
Oral corticosteroids
